ASSESSMENT OF FACTORS INFLUENCING NON-COMPLIANCE TO ANTI-TUBERCULOSIS DRUGS BY PATIENTS ATTENDING CHEST UNIT AT THE UNIVERSITY OF NIGERIA TEACHING HOSPITAL, ENUGU

CHAPTER ONE

INTRODUCTION

Background to the Study

Tuberculosis is a major public health problem in the world and about 9 million people     fell ill with tuberculosis in 2015, including 1.3 million cases among people living with HIV (WHO, 2017). In the same year, over one and half million people died from TB, including 360,000 among people who were HIV positive. Five hundred and ten thousand women died from TB in 2015, including 180,000 among women who were HIV positive    (WHO, 2016). An estimated 550,000 children became ill with TB and 80,000 children who were HIV negative died of TB (WHO, 2017). TB also accounts for about 6.7% of all     deaths in the developing countries; including 18.5% of all deaths of persons between 15 and 45 years of age. This makes TB the greatest cause of death from a treatable disease within the economically productive age group in the world.

                Geographically, the burden of tuberculosis is highest in Asia and Africa; the South East     Asia and Western Pacific Regions as they account for 60% of tuberculosis cases. In Nigeria, tuberculosis is among the ten leading causes of death with an estimated 450,000 cases occurring annually of which more than 50% are smear positive (Ibrahim, Idris, Nguku, Dankoli, Waziri, Obiemem, Ogiri, Oyemakinde, Dalhatu, Nwanyanwu, & Nsubuga, 2011). The incidence of tuberculosis in Nigeria was 133 per 100,000 and mortality rate was 3.4 per 100,000 population in 2015 (Abdullah, 2016), which is considered high compared to other developing countries in the region. Nigeria ranks ninth among the 22 high burden countries that account for 80% of the tuberculosis burden in the world (WHO, 2015).  The social stigma associated with this disease compounds the problem.

                Besides the dangers posed by tuberculosis, the disease is curable. There are essentially six standard drugs for the treatment of tuberculosis. Four of these        drugs, Isoniazid, Rifampicin, Pyrazinamide and Streptomycin are bactericidal while Ethambutol and Thiaceta zone are bacteriostatic. The standard WHO regimen for the treatment of TB involves four drugs for the intensive phase of 2-3 months and two or three drugs for a further “Continuation phase” of 6 – 8 months. The success of TB treatment is the sum of the patients who are cured and those who have completed treatment under the Directly Observed Therapy Short Course (DOTS) strategy. The World Health Organization reported that at least 85% cure rate of all diagnosed TB cases (WHO, 2012). In order to achieve this cure rate, compliance needs to be in the order of 85-90% (Murray, 2010).

Just like many other chronic diseases, unsatisfactory patient compliance with medication is a challenge for TB patients (Baussano, Pivetta, Vizzini, Abbona & Bugiani, 2018). Improper diagnosis and treatment, HIV/AIDS pandemic, presence of multi-resistant  tuberculosis and poor compliance to medication led to deterioration of the disease (WHO, 2017). Majority of tuberculosis patients started on TB treatment do not complete their treatment leading to prolonged infectiousness, relapses, drug resistance and death (Munro, et al, 2011). The World Health Organization (2017) estimates that 1.9% of all new TB cases may be resistant to the first line anti-tuberculosis drugs while among the previously treated TB cases, resistance was about 9.4%.

However, the most important unresolved challenge in tuberculosis control is the treatment completion. This is because treatment will only be effective if the patient completes the regimen which includes a combination of drugs recommended by the physicians. Poor compliance contributes to the worsening of the TB situation by increasing incidence and initiating drug resistance. Resistance to anti-tuberculosis drugs      has also emerged as an important obstacle in the control of the disease. Worldwide patient compliance with anti-tuberculosis therapy is estimated to be as low as 40% in developing countries and remains the principal cause of treatment failure (Fox, 2013).  

It is therefore necessary to study factors influencing non-compliance, default and abandonment of treatment, which are responsible for drug resistance and increased incidence of tuberculosis. Factors that have been reported as being associated with increased compliance by many studies were directly observed therapy (Jonson & Freeman, 2012) and combined short-course regimen (WHO, 2011).

Studies have been conducted to assess non-compliance and determine treatment-related factors, disease related factors, knowledge and attitude related factors and socio-demographic factors, which may have influenced the poor compliance of TB  patients towards anti-TB treatment. Factors that were found as being associated with non-compliance were HIV infection, poverty, increasing immigration (Barnes & Barrows, 2013), intravenous drug user status, alcoholics, unemployment, poor belief and motivation and perceived susceptibility to disease (Sloan & Sloan, 2011).

Though similar studies have been done in other parts of the world, there is still a need    to conduct this study in this region as there are differences compared to other countries in many aspects such as culture, demography, socio-economic status, knowledge level, drugs used, and tolerance to the side effects of drugs.

Statement of Problem

                Tuberculosis remains a major, worldwide public-health problem in the 21st century (WHO, 2017). It is one of the leading causes of morbidity and mortality in Nigeria, and       its elimination remains a major challenge to the Federal Ministry of Health (FMOH, 2014). Although there are treatment regimens that have a greater than 95% efficacy  among tuberculosis patients infected with mycobacterium strains,  there are a number of patients who are unable to comply with treatment in some parts of Africa including Nigeria with a non-compliant rate of 23.0% (Vieira & Ribera, 2012).

                The treatment for tuberculosis in Nigeria is free based on the National Tuberculosis and Leprosy Treatment guidelines. In spite of the free access to anti-tuberculosis drugs, non-       compliance to treatment has been one of the main obstacles to the control of this disease.

Various Studies have been done to identify factors influencing non adherence in other settings. Factors may differ depending on unique population settings and its characteristics: cultural practices, lifestyle, and economic status among others. A nine year review of tuberculosis cases in Enugu, showed a cure rate of 43.7% and a default rate of 44.2%.14 Similar studies in Abakaliki (Ajao, Ogundun & Afolabi, 2014) and Owerri (Ezeala, Atiba, Oguntunase & Nweri, 2013) both in the southeastern part of Nigeria showed cure rates of 73% and 76.6% respectively. It is unclear which factors locally are associated with tuberculosis patients’ noncompliance in Enugu State, South Eastern Nigeria.

During the researcher’s clinical duties at the Chest Unit of the University of Nigeria Teaching Hospital Enugu, she observed that quite a considerable number of patients undergoing tuberculosis treatment were not fully compliant with their anti-tuberculosis medications. This was shown in the left-over drugs patients came back with during                 check-ups. The researcher’s interactions with some of these patients indicated that most of them were non-compliant with their drugs. This has resulted in the development of resistance to first line drugs, prolonged length of hospitalization coupled with financial constraints and serious complications which may lead to death. This finding motivated the researcher to embark on the present study to determine the factors influencing patients’ non-compliance to anti-tuberculosis drugs.

Objectives of the Study

The objectives of the study are:

                1. To identify patient related factors influencing non-compliance to anti-tuberculosis drugs by patients.

                2. To ascertain drug related factors influencing non-compliance to anti-tuberculosis drugs  by patients.

                3. To determine the healthcare provider related factors influencing non-compliance to anti-tuberculosis drugs by patients.

Research Questions

                1. What are the patients related factors influencing non-compliance to anti-tuberculosis  drugs by patients?

                2. What are the drugs related factors influencing non-compliance to anti-tuberculosis drugs by patients?

                3. What are the healthcare provider-related factors influencing non-compliance to anti-tuberculosis drugs by patients?

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